1. CAMHS Overview Dr Mahesh Kulkarni
Consultant Child and Adolescent Psychiatrist
Dr Nefeli Karakitsou
CAMHS Speciality doctor MRCPsych
Dr Jenny Doe
Consultant Clinical Psychologist
Luton & Dunstable hospital

2. Outline Distinction between mental health problems and disorders
Prevalence of mental health problems seen in CAMHS
Risk and protective factors
Specific factors related to CAMHS assessments
Anxiety disorders, Depression

3. Experiment
3 + 5 = = = = 9

4. Prevalence of Mental Health Problems
Distinction needs to be made between mental health problems and disorders

5. Problems: are seen to encompass a very broad range of emotional and behavioural difficulties which may cause concern or distress. They are relatively common and encompass mental disorders
Disorders: are more severe and persistent and usually defined using fairly clear diagnostic criteria

6. World Health Organization
Worldwide 10-20% of children and adolescents experience mental disorders.
Half of all mental illnesses begin by the age of 14 and three-quarters by mid-20s.
Neuropsychiatric conditions are the leading cause of disability in young people in all regions.

7. Common CAMHS Disorders
Mood disorders
Anxiety disorders and OCD
Eating disorders e.g. pre-school or later anorexia / bulimia
Deliberate self-harm
Conduct disorder
Attachment disorders
Hyperactivity & attention problems
Developmental disorders, e.g. delay in acquiring speech, social or other skills or more pervasive developmental disorders, like autism
Habit disorders, e.g. tics, sleeping problems, soiling
Post-traumatic stress syndromes
Psychotic disorders, e.g. schizophrenia, mania, delusional depression, drug-induced states
Kessler et al 2005

8. Risk factors having a long-term physical illness
having a parent who has had mental health problems, problems with alcohol or has been in trouble with the law
experiencing the death of someone close to them
having parents who separate or divorce
having been severely bullied or physically or sexually abused
living in poverty or being homeless
experiencing discrimination
acting as a carer for a relative, taking on adult responsibilities
having long-standing educational difficulties
having learning disabilities
Public Health England, 2016
Physical illness, especially if chronic and/or neurological – having an on-going illness makes a child different to peers. Spells in hospital mean being away from the family, and episodes of illness usually mean falling behind on school work and friends moving on.
Genetic influences – often, when doing assessments, it is discovered that someone else in the family has had a mental health problem. This suggests a genetic link, but again, it is not a predictive factor. Scientists have been trying for decades to identify genetic links and have not been able to prove a predictive gene.
Death and loss – including loss of friendships – grieving is normal when there has been a loss, it becomes a problem if a child or young person is not able to move through the grieving process. If grief is still acute after a year, for example, then this would be considered a problem. That is not to say that the child won’t still miss that person after a year. When children move home or school, they often lose friends, their grief at this loss needs to be acknowledged.
Overt parental conflict – rules may be unclear if parents are saying different things. Living with conflict can be anxiety inducing. Children learn by imitating the behaviours they see around them.
Family breakdown – not always a problem, it’s how it is handled that makes the difference.
Low IQ and learning difficulties – this may be about not being able to express needs, so can’t get them met, leading to frustration and problems.
Kessler et al 2005

9. Resilience factors- child
secure early relationships
being female
higher intelligence
easy temperament when an infant
positive attitude, problem-solving approach
religious faith
capacity to reflect
Kessler et al 2005

10. Resilience factors- family
at least one good parent-child relationship
affection
clear, firm and consistent discipline
support for education
supportive long-term relationship/absence of severe discord
Kessler et al 2005

11. Assessment of mental health problems
Consider:
Age, gender
Type of Symptoms
Severity and frequency of symptoms
Persistence of difficulties
Extent of Disturbance
Change in behaviour
Situation specificity
Life circumstances
Kessler et al 2005

12. Any factors in any of these supra-systems which impinge on the child
Child and the Supra-systems
MGPs
PGPs F M
Child
Neighbours
Teachers
Sib
Sib
Society
Law
Friends
Any factors in any of these supra-systems which impinge on the child

13. Anxiety disorders & mean age of onset
Selective mutism 3-4 years Separation anxiety 6-10 years Specific phobia 5-12 years Social anxiety 8-15 years Agoraphobia years Panic disorder years Generalized anxiety disorder years
The onset of particular types of anxiety disorders often mirrors the normative development of these sort of fears and worries
Kessler et al. 2005
Kessler et al 2005

14. New classification
DSM 5 – OCD – now falls under OC and related disorders , PTSD – trauma and stress related disorders
Kessler et al. 2005

15. Symptoms description
Separation anxiety: Developmentally inappropriate and excessive fear/anxiety concerning separation from those to whom the child is attached, which has been present for at least 4 weeks
Specific phobia: Marked fear/anxiety about a specific object or situation that is out of proportion to the actual danger posed and the sociocultural context and is persistent, typically lasting 6 months or more. The object or situation almost always provokes immediate fear/anxiety and is actively avoided or endured with intense fear/anxiety
Selective mutism: Consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations, for at least 1 month (not limited to the first month of school)
Social anxiety: Marked fear/anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others, occurring in peer settings and not just in interactions with adults. Situations are avoided or endured with intense fear/anxiety, which is out of proportion to the actual threat posed and sociocultural context, typically lasting for 6 months or more
Kessler et al, 2005

16. What Works for Whom, Peter Fonagy et al 2015
Comorbidities
Other anxiety disorders
Depression
ADHD
What Works for Whom, Peter Fonagy et al 2015

17. Treatment of anxiety disorders
Consider developmental state and particular disorder
First line psychological interventions CBT (self-help, individual, groups, parent led)
Second line medication SSRIs; Sertraline best evidence
Combination of CBT and Sertraline better than monotherapy
Cathy Creswell, Polly Waite Evi Based Mental Health August 2016

18. What works for whom, Peter Fonagy et al. 2015
No evidence
Benzodiazepines
Limited research
Small (N=15) placebo-controlled study on the use of Clonazepam produced negative results and reported considerably difficulty with side effects
Double-blind placebo-controlled trial of Alprazolam found no significance difference with placebo.
What works for whom, Peter Fonagy et al. 2015

19. What works for whom, Peter Fonagy et al. 2015
No evidence
TCA Limited and conflicting evidence with the exemption of Clomipramine in OCD
What works for whom, Peter Fonagy et al. 2015

20. What Works for Whom, Peter Fonagy et al. 2015
Prognosis
Only some children with AD go on to have AD/Depression in adulthood
However, most adults with AD/Depression are likely to have a childhood h/o anxiety
What Works for Whom, Peter Fonagy et al. 2015

21. Depression- Diagnostic criteria
Key symptoms (at least one of these, most days, most of the time for at least 2 weeks)
persistent sadness or low mood, and/or
loss of interests or pleasure
fatigue or low energy
Associated symptoms:
disturbed sleep – decreased or increased
poor concentration or indecisiveness
low self-confidence
poor or increased appetite
suicidal thoughts or acts
agitation or slowing of movements
guilt or self-blame
ICD-10
Kessler et al 2005

22. Beck’s cognitive triad
Negative view of self
Negative view of life
Negative view of future

23. Treatment of mild, moderate and severe depression
Mild – watchful waiting, psycho-education
Moderate and severe -
Specific psychological therapy (for at least 3 months)
individual CBT
interpersonal therapy
family therapy
psychodynamic psychotherapy
Offer Fluoxetine if moderate to severe depression is unresponsive to a specific psychological therapy after 4 to 6 sessions.
If treatment with Fluoxetine is unsuccessful or is not tolerated because of side effects, Sertraline or Citalopram are the recommended second‑line
NICE guidelines
Kessler et al 2005

24. Treatment of moderate and severe depression
Unresponsive to combined treatment
MDT needs and risk assessment
Review of diagnosis/ comorbidities
Individual, family and social causes of depression
Assessment for further psychological therapy for the patient and additional help for the family
Adjunctive medication
Inpatient admission
NICE guidelines
Kessler et al 2005

25. When prescribing SSRIs
Monitor for the appearance of
suicidal behaviour,
self‑harm or hostility
particularly at the beginning of treatment
NICE guidelines
Kessler et al 2005

26. Resources Link up with pastoral support at school Mind
Mind provide advice and support to anyone experiencing a mental health problem (information)
Samaritans
Talk to us anythime you like, in your own way and off the record – about whatever’s getting to you (talk anytime)
Get Connected
Get Connected is the UK’s free, confidential helpline service for young people under 25 who need help, but don’t know where to turn (counselling)
Childline
(information, counselling)
Mindfull
Are you feeling down, depressed or worried? Is your mind full of negative thoughts or questions? Do you want to talk about your mental health? If so, MindFull is the place for you! (telephone counselling)
Young Minds
YoungMinds is the UK’s leading charity committed to improving the emotional wellbeing and mental health of children and young people. (parent helpline)
And for anxiety – why not try any of the above or also
Anxiety Care UK
AnxietyUK
Nopanic

27. Resources http://www.stem4.org.uk/
Lots of useful and user-friendly information
An app for dealing with self-harm

28. Thank you
Kessler et al 2005